June 20, 2019 10:57 am Sheri Porter – Are family medicine residents learning the procedural skills they need to care for the nation's fastest growing patient population -- adults age 65 and older?
Researchers wanted to explore that question, and their findings are highlighted in an article(journals.stfm.org) published online May 21 in Family Medicine titled "Essential Office Procedures for Medicare Patients in Primary Care: Comparison With Family Medicine Residency Training."
In an interview with AAFP News, corresponding author Eric Poulin, M.D., of Zumbrota, Minn., a full-time family physician in the Mayo Clinic Health System's Southeast Minnesota Region, stressed the importance of the topic.
"No one really disputes the demographics of the geriatric population increasing in the coming decade," so we should know what kind of care that population needs when it comes to clinic procedures, said Poulin.
"In this study, we set out to answer that question in a different way than I believe has ever been done before," he added. "In previously published studies, it was just a matter of asking expert opinion -- getting groups of family medicine faculty together and asking them what they thought were the most needed procedures. What should be taught? What will patients need?
"This is the first time we went beyond expert opinion to the realm of objective analysis, and you know, sometimes they don't always match up," said Poulin.
In fact, authors wrote, "When the procedural rates for the most common clinic procedures (delivered in a multiregional health care system) were compared with those at a family medicine residency clinic serving a similar population, eight of the 10 most common office procedures in Medicare patients were performed at a lower rate in the residency clinic.
"This implies that the procedural training of family medicine residents may be inconsistent with their future practice patterns."
This retrospective cohort study examined data between Jan. 1, 2014, and Jan. 1, 2017, and included the study group -- all Medicare patients who visited the family medicine residency clinic in Kasson, Minn. -- and a control group that consisted of all Medicare patients who completed appointments with clinicians at a large multiregional health care system with sites in the Upper Midwest, Arizona and Florida.
Researchers queried billing records and CPT coding data for both groups and identified the 10 most common office procedures billed to Medicare in the control group. The procedures were listed as
Authors divided the number of procedures by the total number of evaluation, management and preventive codes in the respective groups to get the rate of procedures per 1,000 office visits.
During the three years of the study, Medicare was billed for more than 2 million office visits by the health care system and for 19,099 patient visits in the residency clinic. Gender and age distributions were similar in both settings.
Researchers discovered that large joint injection was the only clinical procedure performed with similar frequency between the control group and the residency clinic (31.7 versus 32.4 per 1,000, respectively).
Procedure rates were significantly different for the nine other procedures.
Authors noted that the rate of excisions of skin lesions was higher in the residency clinic (7.1 per 1,000) than in the health system control group (4.7 per 1,000).
On the other hand, rates for the remaining eight procedures were much lower in the residency clinic. Consider these examples: nail care (health system 32.6, residency clinic 1.4); punch or shave biopsy, (15.2 versus 5.7); removal of impacted cerumen, (6.7 versus 0.4); and wound debridement (6.5 versus 0.6).
Researchers noted the "rapidly changing medical landscape" where residents are being trained to work in care teams with members working at the tops of their licensure. In that model, nursing staff often perform procedures such as cerumen removal and bladder catheter insertions.
Authors also described a more recent "spectrum of practice patterns" in primary care where family physicians follow either the traditional path of providing comprehensive care themselves or serve as the coordinator of medical services on a team of health care professionals.
In spite of these differing approaches, it's important that residents achieve "competence and confidence" in performing clinic procedures for Medicare patients, said researchers.
"Later, physicians who want to delegate these responsibilities to allied health or nursing staff to improve efficiency will have the necessary experience to supervise more effectively," they added.
Poulin noted that for most of his 19 years practicing family medicine he worked in rural underserved areas in Wisconsin and Minnesota where, by necessity, he offered full-spectrum care.
However, he's noticed in recent years a new trend in residency training
"I fear we've been in this slow slide toward training our residents to be coordinators of care rather than comprehensive providers of care -- and some residents only know the former," said Poulin.
"It takes a pretty fearless person to graduate from a program where he or she has been modeled in coordinating care to then go right out to a rural underserved area, where it's not possible to practice that way, and all of a sudden change.
"There are very few residents who are going to attempt that jump, and that's why we have severe physician shortages out in our rural areas," he added.
Poulin elaborated on that philosophical shift in training.
"We like to say that family physicians specialize in the care of all of the common problems -- some 90% of the medical issues patients might have during their lifetime.
"We're implying that we are actually going to provide the care for those common things, but that seems to be changing. We are specialists in the common things, but then we refer patients to subspecialists for the actual care of those issues," said Poulin.
To highlight this point, Poulin recounted a conversation he recently overheard between two residents who were discussing his research. Both said that they'd never washed out a patient's ears because they always ask a nurse to do so.
"I know from my own experience that about 20% of the time, the nurse comes back to me for help with this procedure," said Poulin.
"So what do you do if you're one of those residents graduating from a program who has never done this procedure, and now you're in practice and you hand a patient needing this procedure off to one of your nurses who can't complete the procedure?
"Well, I'll tell you what you do -- you refer to an ENT because you don't have another option," said Poulin.
Poulin said his primary audience is educators teaching family medicine residents, and his key point centers on the phrase "comprehensive training."
"I'd like them to be very intentional and place comprehensiveness very high on their priority list so that family medicine will be able to serve the increasing geriatric population while serving the best interests of our specialty moving forward," he said.
Poulin noted that a couple of procedures on the study's top 10 list involved podiatry and that residents were given the opportunity to learn those procedures outside of the family medicine clinic.
"But when I went back and asked later how many residents during those three years actually did that elective rotation in podiatry, guess how many did? None. It was not a priority," said Poulin.
"I don't think you're going to have to pull residents kicking and screaming into learning how to do these procedures within their residency program. Residents want to be broadly trained and capable," he added.
Indeed, the authors concluded, "Creating a learning environment where comprehensive care is encouraged and modeled will likely result in graduates who are able and willing to deliver this type of care."
Related AAFP News Coverage
Rocking Full-scope Family Medicine for Rural Patients